EVALUATION AND COMPARISION OF LABOUR ANALGESIA USING ROPIVACAINE 0.2% IN COMBINATION WITH FENTANYL 2g/ml AND BUPIVACAINE 0.

1% IN COMBINATION WITH FENTANYL 2g/ml USING PATIENT CONTROLLED EPIDURAL Saba Ahad , B.N.Seth , S. Dam , Prabhakar Amar Kumar ANALGESIA (PCEA) TECHNIQUE
Department Of Anaesthesiology , Sant Parmanand Hospital , New Delhi , India

Introduction
Amongst other modalities, epidural and spinal analgesia are the most effective methods of intrapartum pain relief in current practice
no. of patients

P value = 0.565 P value 0.05 is significant

Effective epidural analgesia has been found to reduce maternal plasma concentrations of catecholamines which results in improved utero-placental perfusion and more effective uterine activity. Ideal local anaesthetic would provide a rapid onset of effective analgesia with minimal motor blockade, minimal risk of maternal toxicity and negligible effect on uterine activity and utero-placental perfusion. Bupivacaine and Ropivacaine are both amide local anaesthetic with similarity in structure, potency and pharmacodynamics. Ropivacaine is less cardiodepressant and arrythmogenic and does not cause motor block at lower concentrations. By combining an opioid with low concentration of local anaesthetic solution, adequate analgesia can be provided throughout labour, with less motor block, nausea, pruritis and with no neonatal depression.

Fig 3 : Level of Sensory Block

Level of Sensory Block

Objectives
To evaluate and compare effects of epidural ropivacaine 0.2% and bupivacaine 0.1% in combination with fentanyl 2g/ml using patient controlled epidural analgesia technique with regards to : Quality and duration of analgesia Degree of motor block Mode of delivery and duration of labour Perinatal outcome Maternal satisfaction

P value = 0.026 P value 0.05 is significant

Materials and Method

Ethics committee approval Written Informed consent Study Design - Prospective randomized double blind study Sample size - 100 Parturients with established labour and cervical dilatation of 3-5 cm Fig 4 : Duration of Labor Inclusion criteria: Primigravida Age 18 - 30 yrs age ASA I / II Exclusion criteria : ASA physical status 3 or more Age less then 18yrs or more than 30 yrs Parenteral analgesics administration before epidural injection Patients with local infection Bleeding disorders Multiple gestation Inability to understand how to use PCEA pump
no. of patients

P value = 0.481 P value 0.05 is significant

Fig 5 : Mode Of Delivery ID - Instrumental delivery LSCS - Lower section Caesarean section NVD - Normal vaginal Delivery

Group allocation was done randomly with sealed envelopes : Group I Epidural ropivacaine 0.2% in combination with fentanyl 2g/ml
Volume of drug used

Mode of delivery

Group II Epidural bupivacaine 0.1% in combination with fentanyl 2g/ml Technique of Epidural Block : Left lateral position , flexion at hip & knee joint Back prepared and painted with povidine - iodine Under aseptic conditions and local anaesthesia,16 gauge Tuohy needle was inserted in epidural space . 16 gauge epidural catheter passed through the lumen of tuohy needle leaving approx. 3 cm of the catheter inside the epidural space. After negative aspiration, a test dose of 3 ml of 1.5% lidocaine with adrenaline 1:200000 was given A total of 12 ml was given in 4 ml increments over 10 mins. The epidural catheter was connected to PCEA pump Epidural infusion rate set at 8 ml/hr basal infusion and 5 ml bolus. patient controlled, at 15 mins lockout intervals (20 ml/hr limit) .

P value = 0.085 P value 0.05 is significant Fig 6 : Total Volume of Drug Distribution

Monitoring : Heart rate (HR) , non invasive blood pressure (NIBP), oxygen saturation (SpO2

), Fetal heart rate (FHR) using cardiotocography

Statistical Values

Pain assessment : By Visual Analouge Scale 0 being no pain and 10 defined as worst pain Assessed at 2 min interval for first 10 min, 5 min interval until 30 mins, every 15 min till 2 hrs and every 2 hrs till delivery.
Mean FHR

P value at 30 min= 0.045 P value 0.05 is significant Fig 7: Fetal Heart Rate (FHR) Variation

Sensory assessment : By pin prick at bilateral midclavicular line after 30 mins of bolus dose Motor assessment : By Modified Bromage Scale From 0 to 3 Assessed after 30 mins of bolus dose Side effects : Nausea, pruritis and respiratory depression Assessed at 5 mins, 60 min, and 2 hrly intervals.

Time interval Fetal outcome : By Apgar score Assessed at 0, 5 and 10 mins Maternal satisfaction : Noted at the end of the delivery Graded as excellent, fair, satisfactory or unsatisfactory. Total volume of the test drug solution : During the whole duration of labour analgesia & self administered top ups. Statistical Analysis Continuous variables between the groups was performed using Student's t test. Nominal categorical data - Chi-square test or Fischer's exact test. Non-nominal distribution continuous variables - Wilcoxon Rank Sum test. P value = 0.241 P value 0.05 is significant No. of cases Fig 8 : APGAR Score Distribution

APGAR Score

Results
Table 1 : Demographic profile

Fig 9: Mother Satisfaction

Group 1 Age(Yrs) Wt(Kg) Height(cm) 26.742.59 69.18.897

Group 2 26.42.416 67.49.934

P value 0.370 0.084

Group 1 : Epidural ropivacaine 0.2% in combination with fentanyl 2g/ml Group 2 : Epidural bupivacaine 0.1% in combination with fentanyl 2g/ml P value 0.05 is significant

P value = 0.594 P value 0.05 is significant

157.644.91 159.55.926 0.910

Gestational age (wks) 38.982.025 39.72.092

P value for all time intervals for both groups > 0.05 P value 0.05 is significant
Visual Analogue Scale

Discussion
Fig 1 : Visual Analogue Scale distribution (VAS) at different time interval The results in our study demonstrate that 0.2% ropivacaine and 0.1% bupivacaine along with 2g/ml fentanyl are equally effective with no significant differences in VAS, number of bolus doses, level of sensory block, degree of motor block or patient satisfaction.These findings confirm that bupivacaine may be more potent than ropivacaine. A number of studies have compared the analgesic efficacy of equal concentrations of bupivacaine and ropivacaine for obstetrics analgesia concluding relative similar potency. A study by Capogna G. et al observed that epidural ropivacaine was significantly less potent than bupivacaine by a factor of 0.4 when given to women in labour. This is the reason to use different concentrations of the two drugs for labour analgesia in our study.

Time interval

Ropivacaine seems to cause less motor block, particularly in long labours, but this finding may be attributable to differences in drug potency . Although the use of ropivacaine resulted in an increase in the duration of the first stage of labour in parturient who delivered vaginally, there were no differences in other outcomes. It is possible that ropivacaine is less cardiotoxic than bupivacaine when high doses are used, but this is clinically unimportant in the usual dose range used for labour analgesia.

P value = 0.196 P value 0.05 is significant

no. of patients

Conclusion
From a clinical and safety perspective, either drug is a reasonable choice for labour analgesia. Fig 2 :Modified Bromage Scale (MBS).

References
1. Howell CJ, Chalmers I. A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anesth 1992 Jan;1(2):93-110. 2. Shnider SM, Abboud TK, Artal R, HHenriksen EH, Stefani SJ, Levinson G. Maternal catecholamines decrease during labor after lumbar epidural anesthesia. Am J ObstetGynecol 1983 Sep1;147(1):13-5

Modified Bromage Scale

3. America Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for the obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007 Apr; 106(4):843-63. 4. Eisenach JC, Grice SC, Dewan DM. Epinephrine enhances analgesia produced by epidural bupivacaine during labor. Anesth Analg 1987 May;66(5):447-51